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R  J496.  P2  F63         The  nature,  manner  i 


RECAP 


Simon  Floxnor 


The  nature  ...  of  infantile  paralysis 


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I  ■ 

The  Nature,  Manner  of  Conveyance 

and  Means  of  Prevention  of 

Infantile  Paralysis. 


SIMON  FLEXNER,  M.  0 


SUBSTANCE  OF 

AN  ADDRESS  BEFORE 

NEW  YORK  ACADEMY  OF  MEDICINE 

July  13,  1916. 


I'i  BUSHED    i'.v 

Rockefeller  Institute  for  Medical  Research, 

New  York  City. 


•  ' 


THE  NATURE,  MANNER  OF  CONVEYANCE 
AND  MEANS  OF  PREVENTION  OF  IN- 
FANTILE PARALYSIS. 

SIMON  FLEXNEK,  M.  I). 

(Director  of  Laboratories  <>f  The  Rockefeller  institute  for  Medical  Research.) 

The  Rockefeller  [nstitute  for  Medical  Research 
has  beer  appealed  to  by  so  many  physicians  and 
laymen  for  information  and  advice  on  the  subject 
of  infantile  paralysis,  that  it  has  Beemed  desirable 
to  relate  the  Pacts  of  presenl  knowledge  concern- 
ing certain  highly  pertinenl  aspects  <>!'  the  disease, 
together  with  deductions  of  practical  importance 
derived  from  them. 

Nature. 

Infantile  paralysis  is  an  infectious  and  com- 
municable disease  which  is  caused  by  the  invasion 
of  the  central  nervous  organs  the  spinj]  cord 
and  brain — of  a  minute,  filterable  microorganism 
which  has  now  been  secured  in  artificial  culture 
and  as  such  is  distinctly  visible  under  th-  higher 
powers  of  t  he  microsc<  >pe. 

Location  of  the  microorganism  or  virus  in  the  sick. 

The  vims  of  infantile  paralysis,  as  the  micro- 
organism causing  it  is  termed,  exists  constantly 


in  the  central  nervous  organs  and  upon  the  muc- 
ous membrane  of  the  nose  and  throat  and  of  the 
intestines  in  persons  suffering  Prom  the  disease; 
it  occurs  less  frequently  in  the  other  internal  or- 
gans, and  it  has  nol  been  detected  in  the  general 
circulating  blood  of  patients. 


Location  of  the  virus  in  healthy  persons. 

Although  the  microorganism  of  infantile  para- 
lysis is  now  known,  the  difficulties  attending  its 
artificial  cultivation  and  identification  under  the 
microscope  are  such  as  to  make1  futile  the  employ- 
ment of  ordinary  bacteriological  tests  for  its  de- 
tection. Nevertheless,  the  virus  can  be  detected 
by  inoculation  tests  upon  monkeys,  which  animals 
develop  a  disease  corresponding  to  infantile  para- 
lysis in  human  beings.  In  this  manner  the  facl 
has  been  determined  that  the  mucous  membrane 
of  the  nose  and  throal  of  healthy  persons  who 
have  been  in  intimate  contact  with  acute  cas< 
infantile  paralysis  may  become  contaminated  with 
the  vims,  ;ind  thai  such  contaminated  persons. 
without  falling  ill  themselves,  may  convey  the  in- 
fection to  other  persons,  chiefly  children,  who  de- 
velop the  disease. 


Relation  of  virus  to  types  of  the  disease. 

The  virus  has,  apparently,  an  identical  distri 
bution   irrespective  of  the  types  or  severity  of 
oases  "i'  infantile  paralysis.     Whether  the  cases 
correspond  with  the  so-called  abortive  form-  ol 

the  disease  in  which  definite  paralysis  ^\'  the 
muscles  docs  not  occur  ;>t  all,  or  is  so  Blight  and 
fleeting  as  often  to  escape  detection;  whether  they 

•J 


correspond  with  the  meningeal  forms  in  which 
tlif  symptoms  resemble  those  of  acute  meningi- 
tis with  which  muscular  paralysis  may  or  may 
not  be  associated;  or  whether  they  consist  of  the 
familiar  paralytic  condition,  the  virus  is  presenl 
not  onlv  within  the  nervous  organs,  but  also  up- 
on the  mucous  membranes  of  the  nose,  throat  and 
intestines 


Escape  of  the  virus  from  the  body. 

Microorganisms  which  convey  disease  escape 
from  the  body  of  an  infected  individual  in  a  man- 
ner enabling  them  to  enter  and  multiply  within 
fresh  or  uninfected  individuals  in  such  a  man 
ncr  as  to  cause  further  disease.  The  virus  "I'  in- 
fantile paralysis  is  known  to  Leave  the  infected  hu- 
man body  in  the  secretions  of  the  nose,  throat, 
and  intestines.  It  also  escapes  from  contaminated 

healthy  persons  in  the  secretions  of  the  nose  and 

throat.    Whether  it  ever  leaves  the  infected  body 

in  other  ways   is  unknown.     At   one  time  certain 

experiments  seemed  to  show  that   biting  insects 

and  particularly  the  stable  fly  might  withdraw  the 
vims  from  the  blood  of  infected   persons  and   in 

oculate  it  into  the  blood  .if  healthy  persons.    Bui 

as  the  vims  ha-  never  been  detected  ill  tile  blood 
of  human   being8  and   later  experiments  with  the 

stable  fly  have  not  confirmed  the  earlier  one-. 
this  means  of  escape  of  the  virus  must  he  consid- 
ered doubtful.  On  the  other  hand,  it  has  been 
shown    by    experiments    on    animals,    so    ihat    the 

same  facts  should  be  regarded  as  applicable  to 
human  beings,  that  the  virus  seek    t<>  escape  from 

the  body  by  way  of  the  nose  and  throat,  net  only 
when  inoculation  takes  place  through  these  mem 

branes«  bni  also  when  the  inoculation  is  experi 

3 


mentally  made  into  the  abdominal  cavity,  the 
blood,  or  Ili<'  brain  itself.  From  this  it  is  con- 
cluded thai  the  usual  means  of  escape  of  the  virus 
is  by  way  of  the  ordinary  secretions  of  the  nose 
and  throat  and,  after  swallowing  these,  with  the 
discharges  of  the  intestines. 


Entrance  of  the  virus  into  the  body. 

The  virus  enters  the  body,  as  a  rule  if  not  ex- 
clusively, by  way  of  the  mucous  membrane  of  the 
nose  and  throat.  Saving  gained  entrance  to  those 
easily  accessible  parts  of  the  body,  multiplication 
of  the  vims  occurs  there,  after  which  it  penetrates 
to  the  brain  and  spinal  cord  by  way  of  the  lymph 
atic  channels  which  connect  the  upper  aasal  mem- 
brane with  the  interior  of  the  skull.  Whether  tbe 
virus  ever  enters  the  body  in  any  other  way  is  nn 

known.    Certain  experiments  already  alluded  to 
make  it   possible  that   it  may  be  inoculated  into 
the  blood  by  insects,  and  other  experiments  have 
shown  that  under  peculiar  and  extraordinary  con 
ditions,  it  may  in  monkeys  enter  through  the  in 

teslines.      But    while  the  latter   two   modes  of  in 

fection  may  operate  Bometimes,  observations  up 
on  human  eases  of  infantile  paralysis  and  upon 

animals  all  indicate  thai    the  main  avenue  of  en 

trance  of  tbe  virus  into  the  bodj  is  by  way  <>!' 
the  upper  respiratory  mucous  membrane  thai  is, 
the  membrane  of  the  nose  and  throat. 


Resistance  of  the  virus. 

The  physical  properties  of  the  virus  of  infan 
tile  paralysis  adapt  it  well  for  conveyance  to  the 
nose  and  throat.    Being  contained  in  their  secre 


tions,  ;t  i-  readily  distributed  by  coughing,  sneez 
Lng,  kissing,  and  by  means  of  fingers  and  articles 
contaminated   with   these   secretions,   as   well   as 
with  the  intestinal  discharges.     Moreover,  as  the 
virus  is  tin-own  off  from  the  body  mingled  with 
the  secretions,  it  withstands  for  a  long  time  even 
the  highest  summer  temperatures,  complete  dry 
ing,  and  even  the  action  of  weak-  chemicals,  such 
as  glycerin  and  carbolic  acid,  which  destroy  or- 
dinary bacteria.    Hence  mere  drying  of  the  secre- 
tion- is  ao  protection;  on  the  contrary  as  the  dried 
secretions   may  he   converted    into  dnst    which   is 
breathed  into  the  nose  and  throat,  they  become 
a.  potential  source  of  infection.     The  survival  of 
the  virus  in  the  secretions  is  favored  by  weak  day 
lighl  and  darkness,  and  hindered  by  brighl  day 
light  and  sunshine.    11  is  readily  destroyed  by  ex- 
posure to  sunlight. 


Conveyance  by  insects. 

Since  epidemics  of  infantile  paralysis  always 
arise  during  the  period  of  warm  or  summer  weath 
er,  they  have  l»'«'ii  thought  of  as  possibly  being 
connected  with  or  dependent  on  insect  lif<\  The 
blood-sucking  insects  have  especially  come  under 
suspicion.  Experiments  have  been  made  with  hit 
ing  (lies,  bed-bugs,  mosquitoes,  and  with  lice. 
Neither  mosquitoes  nor  lice  seem  able  to  take  the 
virus  from  the  blood  of  infected  monkeys  <>r  to 
retail!   it    for  a   tune   in  a  living  -tale.      In  one  in 

-lance,  bed  bugs  have  been  made  to  take  up  the 
virus  from  the  blood  of  monkeys,  hut  they  did  not 
convey  it  by  biting  to  healthy  monkeys.  Certain 
experiments  did  indicate  that  the  biting  stable  fly 
could  both  withdraw  the  vims  from  the  blood  of 
infected   ;ind    nrniivcv    it    to  the   hlood    of  healthy 


5 


monkeys,  which  became  paralyzed.  But  more  re- 
cenl  studies  have  failed  to  confirm  the  earlier  ones. 
Moreover,  experimentally  inoculated  monkeys  dif- 
fer in  one  way  from  human  beings  suffering  from 
infantile  paralysis,  for  while  the  virus  may  appear 
if  the  blood  of  the  former,  it  lias  never  been  de 
tected  in  lli<i  blood  of  the  latter.  The  ordinary 
or  domestic  fly  may  become  contaminated  with  the 
virus  contained  in  the  secretions  of  the  body  and 
serve  as  the  agenl  of  its  transportation  to  persons 
and  to  food  with  which  they  come  into  contact. 
Domestic  Mies  experimentally  contaminated  with 
the  virus  remain  infective  for  48  hours  or  longer. 
While  our  present  knowledge  excludes  insects 
from  being  active  agents  in  the  dissemination  of 
infantile  paralysis,  they  nevertheless  fall  under 
suspicion  as  being  potential  mechanical  carriers 
of  the  virus  of  that  disease. 


Conveyance  by  domestic  animals. 

The  attention  which  the  recenl  epidemic  of  in 
Inutile   paralysis  has  drawn   to  the  diseases  at- 
tended by  paralysis  has  led  to  the  discovery  that 

domestic  animals  and   pets  are  subject   to  parak 

tic  diseases.  The  animals  which  have  especially 
come  under  suspicion  as  possibly  distributing!  the 
germ  of  infantile  paralysis  are  poultry,  pigs,  and 
dogs,  and  cats.  Bui  in  isolated  instances,  sheep, 
cattle,  and  even  horses  have  been  suspected.    All 

Ihese  kinds  of  animals  are  subjed  to  diseases  in 
which  paralysis  of  the  legs  and  other  parts  of  He' 
bodj  sometimes  appear.  In  not  a  few  instances, 
paralytic  disease  among  poultry  or  pigs  have  been 
noted  to  coincide  with  the  appearance  of  cases 
<>!'  infantile  paralysis  mi  a  farm  or  in  a  commun 
Hy.     Experimental  studies  have,  however,  exclu 


dec!  the  above-mentioned  animals  from  being  car- 
riers of  the  virus  of  infantile  paralysis.  The  para- 
lytic diseases  which  they  suffer  have  long  been 
known  and  are  quite  different  from  Infantile  para- 
lysis. Their  occurrence  may  be  coincidental;  in 
no  instance  investigated  has  one  been  found  to 
be  responsible  for  the  other. 


Routes  of  travel. 

Studies  carried  out  in  various  countries  in  which 
infantile  paralysis  has  been  epidemic  all  indicate 
that,  in  extending  from  place  to  place  or  point 
to  point,  the  route  taken  is  that  of  ordinary 
travel.  This  is  equally  true  whether  the  route 
IS  by  water  or  land,  along  a  simple  highway 
or  the  line  of  a  railroad.  In  other  words, 
the  evidence  derived  from  this  class  of  studies 
Confirms  the  evidence  obtained  from  oilier  sources 
in  connecting  the  distributing  agency  intimate- 
ly with  human  beings  and  their  activities. 


Survival  of  the  virus  in  the  infected  body. 

The  virus  of  infantile  paralysis  is  destroyed  in 
the  interior  of  tin-  body  more  quickly  ami  com 

pletely    than,    in    some    instances,    in    the    mUCOUS 

membrane  of  the  nose  and  throat.     It  has  been 
found  in  monkey-,  in  which  accurate  experiments 

ean   he  carried  out,  thai    the  virus  may  disappear 
from  the  brain  and  spinal  cord  within  a  few  days 

to  three  weeks  after  the  appearance  of  the  para 

lysis,  while  at   1  he  same  lime  il  is  st  ill  presenl   up 

on  the  mucous  membranes  mentioned.    The  long 
est  period  after  inoculation  in  which  Hie  virus  has 
been  detected  in   the  mucous  membrane  of  the 


nose  and  throat  of  monkeys  is  six  months.  It  is 
far  more  difficult  to  detect  the  human  than  the 
monkey  carriers  of  the  virus  since,  as  directly  ob- 
tained from  human  beings,  the  virus  displays  a 
low  degree  of  Lnfectivity  for  monkeys;  while  once 
adapted  to  monkeys,  the  virus  becomes  incredi- 
bly active,  so  that  minute  quantities  are  capable  of 
ready  detection  by  inoculation  tests.  Vet  in  an 
undoubted  instance  of  the  human  disease,  the 
virus  was  detected  in  the  mucous  membrane  of 
the  throat  five  months  after  its  acute  onset.  Hence 
w,»  possess  conclusive  evidence  of  the  occurrence 
of  occasional  chronic  human  carriers  of  the  virus 
of  infantile  paralysis. 


Fluctuation  in  epidemics. 

Not  all  epidemics  of  infantile  paralysis  arc 
equally  severe.  Indeed  great  variations  or  fluc- 
tuations are  kown  to  occur  not  only  in  the  number 

of  cases,  hut  also  in  the  death  rate.  The  extremes 
are  represented  by  the  occasional  instances  of  in- 
fantile paralysis  known  in  every  considerable  com- 
munity and  from  which  no  extension  take-  place, 
and  the  instances  in  which  in  a  few  days  or  weeks 

the  number  of  cases  rises  by  leaps  and  bounds  into 
the  hundreds,  and  the  death  rate  reaches  20  per 
cent  or  more  of  those  attacked.  While  all  the 
factors  which  determine  this  discrepancy  are  not 
known,  certain  of  them  have  become  apparent. 
A  factor  of  high  importance  is  the  infective  pow- 
er or  potency,  or  technically  Btated  the  virulence, 
of  t he  microorganism  or  virus  causing  the  disease. 
This  virus  is  subject  to  fluctuations  of  intensity 
which  can  hest  l»e  illustrated  by  an  example.  The 
virus  as  ordinarily  present  in  human  beings  even 
during  Bevere  epidemics  has  l<»\\   infective  power 

8 


for  monkeys.  But  by  passing  it  from  monkey 
to  monkey,  it  tends  to  acquire  after  a  variable 
number  of  such  passages  an  incredible  activity. 
However,  occasional  samples  of  the  human  vi- 
rus refuse  to  be  thus  intensified.  But  once  ren- 
dered highly  potent,  the  virus  may  be  passed 
from  monkey  to  monkey  through  a  long  but  not 
indefinite  series.  Finally,  in  some  samples  of 
the  virus  a1  least  a  reverse  change  takes  place — 
the  virus  begins  to  lose  its  virulence  until  it  re- 
turns to  the  original  or  even  to  a  diminished  de- 
gree of  infective  power.  In  this  respect  the  be- 
havior of  the  virus  corresponds  to  the  onset,  rise 
and  then  the  fall  in  number  and  severity  of  eases 
as  observed  in  the  course  of  epidemics  of  infan- 
tile paralysis  and  other  epidemic  diseases.  Hence 
either  a  new  active  specimen  of  the  virus  may  be 
introduced  from  without  which,  after  a  certain 
number  of  passages  from  person  to  person,  ac- 
quires a  high  potency;  or  a  specimen  of  virus  al- 
ready present  and  left  over  from  a.  previous  epi- 
demic after  a  resting  period  and  similar  passages, 
again  becomes  active  and  reaches  an  infective 
power  which  equals  or  even  exceeds  that  origin- 
ally possessed.  Another  but  more  indefinite 
factor    relates    to   the    degree    of    susceptibility 

among  children  and  others  affected  which  at   one 

period  may  be  greater  or  less  than  at  another. 

Varying  individual  susceptibilities. 
Nbl  all  children  and  relatively  few  adults  are 

susceptible  to  infantile  paralysis.  Young  chil- 
dren are  more  susceptible  generally  speaking 
than  older  ones;  but   no  age  can  be  Baid  to  be 

absolutely  insusceptible.  When  several  children 
exist  in  a  family  or  in  a  group,  one  or  more  may 


be  affected,  while  the  others  escape  or  seem  to 
escape.  The  closer  the  family  or  other  groups 
an-  studied  by  physicians,  the  more  numerous  it 
now  appears  are  the  number  of  cases  among 
them.  This  means  that  the  term  infantile  par- 
alysis is  a  misnomer,  since  the  disease  arises 
without  causing  any  paralysis  whatever,  or  such 
slight  and  fleeting  paralysis  as  to  be  difficult  of 
detection.  The  light  or  abortive  cases,  as  they 
are  called,  indicate  a  greater  general  suscepti- 
bility than  has  always  been  recognized;  and  their 
discovery  promises  to  have  far-reaching  conse- 
quences in  respect  to  the  means  employed  to 
limit  the  spread  or  eradicate  foci  of  the  disease. 


Period  of  incubation. 

Like  all  other  infectious  diseases,  infantile  par- 
alysis does  not  arise  at  once  after  exposure,  but 
only  after  an  intervening  lapse  of  time  called  the 
pniod  of  incubation.  This  period  is  subject 
to  wide  limits  of  fluctuation:  in  certain  instances 
it  has  been  as  short  as  two  days,  in  others  it 
lias  been  two  weeks  or  possibly  even  longer.  But 
the  usual  period  does  not  exceed  about  eight  days. 


Period  of  infectivity. 

Probably  the  period  at  which  the  danger  of 
communication  is  greatest  is  during  the  very 
early  and  acute  Btage  of  the  disease.    This  state 

nient    must    he   made   tentatively    since    it    depends 

on  inference,  based  <>n  general  knowledge  of  in 
fection,  rather  than  on  demonstration.    Judging 

from  experiments  on  animals,  the  virus  tends  not 

10 


to  persisl  in  the  body  longer  than  four  or  five 
weeks  excepl  iii  those  exceptional  instances  in 
which  chronic  carriage  is  developed.  Hence  cases 
of  infantile  paralysis  which  have  been  kepi  under 
supervision  for  a  period  of  six  weeks  from  tlie 
onset  of  the  symptoms  may  be  regarded  as  prac- 
t iealh  free  of  danger. 


Protection  by  previous  attack. 

Infantile  paralysis  is  oik?  of  the  infectious  <lis 
ss   in   which   insusceptibility   is  conferred   l>> 
one  attack.     The  evidence  derived  from  experi- 
ments  on  monkeys  is  conclusive  in  showing  that 
an    infection    which    ends    in    recovery   gives    pic 
lection  from  a  subsequenl  inoculation.    Observa- 
tions upon  human  beings  have  broughl   out   the 
same  fact,  which  appears  to  he  generally  true. 
and  to  include  all  the  forms  of  infantile  paraly 
sis,  namely  the  paralytic,  meningeal,  or  abortive, 
which  all  confer  immunity. 


Basis  of  the  immunity. 

The  blood  of  normal  persons  and  monkeys  is 
not    capable   of   destroying   or   neutralizing   the 
effecl   of  the  virus  of  infantile  paralysis.     The 
blood  of  persons  or  monkeys  who  have   recov 
ered  from  the  disease  is  capable  of  destroying  or 
neutralizing  the  effecl   of  the  virus.     The  insus 
ceptibility  or  immunity  to  Bubsequenl   infection. 
whether   occurring    in    human    beings   after   ex 
posure  or  monkeys  after  inoculation,  rests  on  the 
presence  of  the  destroying  substances,   the   bo 
called    immunity    bodies,   which   arise   in   the   in 

I  l 


ternal  organs  and  are  yielded  to  the  blood  So 
long  as  these  immunity  bodies  persisl  in  the  body, 
protection  is  afforded;  and  their  presence  has 
been  detected  twenty  years  or  even  longer  after 
recovery  from  infantile  paralysis.  Experiments 
have  shown  thai  the  immunity  bodies  appear  in 
the  blood  in  the  course  of  even  the  mildest  at- 
tack of  the  disease,  which  \';[d  explains  why  pro 
tection  is  afforded  irrespective  <>f  the  severity  of 
the  case. 


Active  immunization. 

Protection  has  been  afforded  monkeys  againsl 
inoculation  with  effective  quantities  of  the  virus 
of  infantile  paralysis  by  previously  subjecting 
them  to  inoculation  with  sub-effective  quantities 
or  "loses  of  the  virus.  By  this  means  and  without 
any  evidenl  illness  or  effect  of  the  protective 
inoculation,  complete  immunity  has  been 
achieved.  Bui  the  method  is  not  perfect  since  in 
certain  instances  not  only  was  immunity  not  ob- 
tained, but  unexpected  paralysis  intervened.  In 
the  instances  in  which  protection  was  accom 
plished,  the  immunity  bodies  appeared  in  the 
blood. 


Passive  protection. 

I'.\  transferring  the  blood  of  immune  monkeys 
to  normal  or  untreated  ones,  they  can  he  ren 
dered  insusceptible  <>r  immune,  and  the  immunity 
will  endure  for  a  relatively  shint  period  during 
which  the  passively  transferred  immunity  bodies 
persist.    The  accomplishment  of  passive  immun 


ization  is  somewhat  uncertain,  and  its  brief  dura- 
tion renders  it  useless  for  purposes  of  pro- 
tective immunization. 


Serum  treatment. 

On  the  other  hand,  a  measure  of  success  has 
been  achieved  in  the  experimental  serum  treat- 
ment of  inoculated  monkeys.  For  this  purppse 
blood  serum  derived  either  from  recovered  and 
protected  monkeys  or  human  beings  has  been 
employed.  The  serum  is  injected  into  the  mem- 
branes aboul  the  spinal  cord,  and  the  virus  is 
inoculated  into  the  brain.  The  injection  of  serum 
musl  be  repeated  several  times  in  order  to  be 
effective.  Use  of  this  method  has  been  made  in 
a  few  instances  in  France  where  the  blood  Berum 
derived  from  persons  who  had  recovered  from 
infantile  paralysis  lias  Keen  injected  into  the 
spinal  membranes  of  persons  who  have  just  be- 
come paralyzed.  The  results  are  said  to  be 
promising.  Unfortunately,  the  quantity  of  the 
human    immune    scrum    is    wry    limited,    and    no 

other  animals  than  monkeys  seem  capable  of 
yielding  an  immune  Berum  and  the  monkey  is 
not  a  practicable  animal  from  which  to  obtain 
supplies. 


Drug  treatment. 

Thf  virus  of  infantile  paralysis  attacks  and 
attaches  itself  to  the  central  nervous  organs. 
Hence  it  is  reached  not  only  with  difficulty  be- 
cause nature  has  carefully  protected  those  sensi- 
tive organs  from  injurious  materials  which  may 


L3 


gain  access  to  the  blood,  but  it  must  be  counter- 
acted by  substances  and  in  a  manner  that  will 
not  themselves  injure  those  sensitive  parts.  The 
ideal  means  to  accomplish  this  purpose  is 
through  the  employmenl  of  an  immune  serum, 
since  serums  are  among  the  least  injurious  thera- 
peutic agents.  The  only  drug  which  has  shown 
any  useful  degree  of  activity  is  hexamethylena- 
min  which  is  itself  germicidal,  and  has  the  merit 
of  entering  the  membranes,  as  well  as  the  sub- 
stance of  the  spinal  cord  and  brain  in  which  the 
virus  is  deposited.  But  experiments  <>n  monkeys 
nave  shown  this  chemical  to  be  effective  only 
very  early  in  the  course  of  the  inoculation  and 
only  in  ;i  part  of  the  animals  treated.  Efforts  to 
modify  and  improve  this  drug  by  chemical  means 
have  up  to  the  present  been  only  partially  sue 
cessful.  The  experiments  have  not  yet  readied 
the  point  where  the  new  drugs  are  applicable  to 
tic  treatment  of  human  cases  of  infantile  paral- 
vsis. 


Practical  Deductions  and  Applications. 

1.  The   chief   mode   of   demonstrated   convey 
ance  of  the  virus  is  through  the  agency  of  hu- 
man  beings.      Whether  still    other   modes   of  dis- 
semination exist   is  unknown.     According  to  our 
present  knowledge,  the  virus  leases  the  body  in 

the   secretions   of  the   nose  and   throat    and   in    the 

discharges  from  the  intestines.     'The  conveyers 

of  the   virus    include   persons   ill   of   infantile   par 

alysis  in  any  of  its  several  forms  and  irrespeel 
ive  of  whether  they  are  paralyzed  or  not,  and 
such  healths  persons  who  may  have  become  con 

laminated    le,    attendance    on    or    association    with 


1  I 


the  ili.  How  numerous  the  latter  class  may  be 
is  unknown.  But  all  attendants  on  or  associates 
of  the  sick  are  suspect.  These  healthy  carriers 
rarely  themselves  fall  ill  of  the  disease;  they 
may,  however,  he  the  source  of  infection  in 
others.  On  the  other  hand,  the  fact  that  infan- 
tile paralysis  is  very  rarely  communicated  in 
era!  hospitals  to  other  persons,  whether  doctors, 
nurses,  or  patients,  indicates  that  its  spread 
is  subject  to  ready  control  under  restricted  and 
supervised  sanitary  conditions. 

2.  The  chief  means  by  which  the  secretions 
of  the  nose  and  throat  are  disseminated  is 
through  the  act  of  kissing,  coughing,  or  Bneezing. 
Hence  during  the  prevalence  of  an  epidemic  of 

infantile  paralysis,  care  should   be  exercised   to 
restrict     the     distribution     as     far     as     possible 
through  these  common  means.     Habits  of  Belf 
denial,  care,  and  cleanliness   and  consideration 

for  the  public  welfare  can  be  made  to  go  very  far 

in  limiting  the  dangers  from  these  Bources. 

Moreover,  since  the  disease  attacks   hy   prefer 
ence  young  children  and   infants,   in   whom   the 
secretions    from   the    nose   and    month    are   wiped 
away    by    mother   or    nurse,    the    fingers    of    these 

persons  readily  become  contaminated.  Through 
attentions  on  other  children  or  the  preparation 
of  food  which  may  be  contaminated,  the  virus 
may  thus  be  conveyed  from  the  sick  to  the 
healthy.  The  conditions  which  obtain  in  a  house 
hold    in    which    ;i    mother    waits   on    the    sick    child 

and  attends  tin'  other  children  ;nv  directlj   con 
trasted    with    those   existing    in    a    well-ordered 
hospital:  the  on.-  is  ;i  menace,  ili'1  other  a  pro 
lection    to   iIm-   comunity.     Moreover,    in    homes 
(|jr   practice   of   carrying   small   children    about 

L6 


and  comforting  them  is  the  rule,  through  which 

not  only  the  Lands,  but  other  parts  of  the  body 
and  the  clothing  of  parents  may  become  con- 
taminated. 

3.  Flies  also  often  collect  about  the  nose  and 
mouth  of  patients  ill  of  infantile  paralysis  and 
feed  on  the  secretions,  and  they  even  gain  access 
to  the  discharges  from  the  intestines  in  homes 
unprotected  by  screens.  This  fact  relates  to  the 
domestic  fly,  which  becoming  grossly  contamin- 
ated with  the  virus,  may  deposit  it  on  the  nose 
and  mouth  of  healthy  persons,  or  upon  food  or 
eating  utensils.  To  what  extent  the  biting  stable 
fly  is  to  be  incriminated  as  a  carrier  of  infection 
is  doubtful;  but  we  already  know  enough  to  wish 
to  exclude  from  the  sick,  and  hence  from  men- 
acing the  well,  all  objectionable  household  in 
sects. 

Food  exposed  to  sale  may  become  contamin- 
ated by  fles  "!•  Prom  Angers  which  have  been  in 

contact  with  secretions  containing  the  virus; 
hence  food  should  not  be  exposed  in  shops  ;md 
no  person  in  attendance  upon  ;i  case  of  infantile 

paralysis  should  be  permitted  to  handle  food  for 
Bale  to  the  general  public. 

4.  Protection  to  the  public  can  be  best  se- 
cured   through    the   discovery    and    isolation    of 

those  ill  of  the  disease,  and  the  sanitary  ( fcrol 

of  those  pei-sons  who  have  associated  with  the 

Bicb    and    whose    business   calls    them    away    from 

home.  Both  these  conditions  can  be  Becured 
without  too  greal  interference  with  the  comforts 
and  the  rights  of  individuals. 

In  the  first  place  where  home-  are  not  suited 
to  the  care  of  the  ill  so  thai  othei  children  in  the 
same  or   adjacent    families   are  exposed,   the   par 


Hi 


ent  should  consent  to  removal  to  hospital  in  the 
interesl  of  the  sick  child  itself,  as  well  aa  in  the 
interest  of  other  children.  But  this  removal  or 
care  must  include  do1  only  the  frankly  paralyzed 
cases,  hut  also  the  other  forms  of  the  disease.  In 
the  event  of  doubtful  diagnosis,  the  aid  of  the 
laboratory  is  to  be  soughl  since  even  in  the  mild- 
est eases  changes  will  he  detected  in  the  cere 
brospinal  fluid  removed  by  lumbar  puncture.  If 
the  effort  is  to  be  made  to  control  the  disease 
by  isolation  and  segregation  of  the  ill,  then  these 
means  musl  be  made  as  inclusive  as  possible.  It 
is  obvious  that  in  certain  homes  isolation  can  be 
carried  out  as  effectively  as  in  hospitals. 

But  what  has  been  said  of  the  small  incidence 
of  cases  of  the  disease  among  the  hospital  per 

SOnnel  and  those  with  whom  they  come  into  con- 
tact, indicates  the  extent  to  which  persona]  care 
of  the  body  by  adults  and  responsible  people  can 
diminish  the  menace  which  those  accidentally  or 
unavoidably  in  contact  with  the  ill  are  to  the 
community.  Care  exercised  not  t<>  scatter  the  se 
cretions  of  the  nose  mid  throat  by  spitting, 
coughing  and  Bneezing,  the  free  use  of  clean 
handkerchiefs,     cleanliness     in     habits     affecting 

especially  the  hands  and  face,  changes  of  clothes, 

etc.,   should    all    serve   to   diminish    this   danger. 

In  the  end,  the  early  detection  and   isolation 

of   the   cases    of    infantile    pnral\Ms    in    all    of    its 

forms,  with  the  attendant  control  of  the  house 
holds  from  which  they  come,  will  have  t"  be  re 
lied  upon  as  the  chief  measure   of  staying  the 
progress  of  tin-  epidemic. 

."».     The    degr f    Busceptibilitj    "f   children 

and    other    members    of   the   community    '"    in 
fantile    paralysis     is    relatively     -mall    and    is 


17 


definitely  lower  than  to  such  communicable  dis- 
eases as  measles,  scarlet  fever,  and  diphtheria. 
This  fact  in  itself  constitutes  a  measure  of  con- 
trol; and  while  it  does  not  justify  the  abate- 
ment of  any  practicable  means  which  may  be 
employed  to  limit  and  suppress  the  epidemic, 
it  should  tend  to  prevent  a  state  of  over-anxiety 
and  panic  from  taking  hold  of  the  community. 

6.  A  percentage  <»t'  persons,  children  partic- 
ularly, die  during  the  acute  stage  of  the  dis- 
ease. This  percentage  varies  from  five  in  cer- 
tain si  vere  epidemics  t<>  twenty  in  others.  The 
average  death  rate  of  many  epidemics  has  been 
below  10  per  cent.  A  reported  high  death  rate 
may  not  be  actual,  hut  only  apparent,  since  in 
every  instance  the  death  will  he  recorded,  while 
many  cases  which  recover  may  not  he  reported 
at  all  to  the  authorities.  Iii  the  present  in- 
stance it  is  too  early  in  the  course  of  the  epi- 
demic to  calculate  the  death  rate  which  may 
prove  to  l»'  considerably  lower  than  it  now  senn> 

to    he. 

7.  Of  those  who  survive,  a  part  make  com 
plete  recoveries,  in  which  no  crippling  whatever 
remains.  This  number  is  greater  than  is  usually 
Bupposed,  because  it  includes  not  < » 1 1 1 \  the 
relatively  large  number  of  Blight  or  abortive 
oases,  hut  also  a  considerable  number  of  cases 
in  which  more  or  less  of  paralysis  was  presenl 
at  one  time.  The  disappearance  of  the  paralysis 
may  he  rapid  or  gradual  may  ^^'  complete  in 
a    few   days   or   maj    require   Beveral    weeks   "i 

Iliollt  lis. 

The  remainder,  and  unfortunately  not  a  small 
number,  Buffer  Borne  degr t   permanent   crip 

is 


pling.  But  even  in  this  class,  the  extent  to 
which  recovery  from  the  paralysis  may  occur 
is  very  great.  In  many  instances  the  residue  of 
paralysis  may  be  so  small  as  not  seriously  to 
hamper  the  life  activities  of  the  individual;  in 
others  in  whom  it  is  greater  it  may  be  relieved 
or  minimized  by  suitable  orthopedic  treatment. 
But  what  it  is  imperative  to  keep  in  mind  is 
that  the  recovery  of  paralyzed  parts  and  the 
restoration  of  lost  muscular  power  and  function 
is  a  process  which  extends  over  a  long  period 
of  time — that  is,  over  months  and  even  years. 
So  that  even  a  severely  paralyzed  child  who 
has  made  little  recovery  of  function  by  the  time 
the  acute  stage  of  the  disease  is  over,  may  go 
on  gaining  for  weeks,  months,  and  even  years 
until  in  the  end  he  has  regained  a  Large  part 
of  his  losses.  Fortunately,  only  a  very  small 
number  of  the  attacked  are  lefl  severely  and 
helplessly  crippled.  Lamentable  as  it  is  that 
even  one  should  he  so  affected,  it  is  neverthe- 
less a  reassurance  to  know  that  so  many  recover 
altogether  and  so  much  of  what  appears  to  be 
permanenl  paralysis,  disappears  in  time. 

There    exists    at     present     no    safe    method    of 

preventive  inoculation  or  vaccination,  and  no 
practicable  method  of  specific  treatment.  The 
prevention  of  the  disease  must  he  accomplished 
through  general  sanitary  means;  recovery  from 
the  disease  is  a  spontaneous  process  which  can 
he  greatly  assisted  by  proper  medical  and  sur 
gical  care,  [nfantile  paralysis  is  an  infectious 
disease,  due  to  a  definite  and  specific  microor 
ganism  or  virus;  recovery  is  accomplished  by 
a  process  of  immunization  winch  takes  place 
during  the  acute  period  of  the  diseasi  Tic 
tendency  of  the  disease  i-  toward  recovery   ami 

ID 


I 


I     ••  ''■■"■■■■•<    '    t     '     ■  >'  ' 

■.-..:  .... 

I    I  . ,, 

I     I 


•  •  • '  i       r> 


it  is  chiefly,  or  only  because  the  paralysis  in 
some  instances  Involves  those  portions  of  the 
brain  and  spinal  cord  which  control  respiration 
or  breathing  and  the  heart's  action,  that  death 
results. 

Finally,  it  should  be  added  that  not  since  L907, 
at  which  time  the  great  epidemic  of  infantile  par- 
alysis, or  poliomyelitis,  appeared  in  this  country, 
has  the  country  or  this  State  or  city  been  free  of 
the  disease.  Bach  Summer  since  has  seen  some 
degree  of  accession  in  the  number  of  the  ca 
the  rapid  rise  in  the  number  of  cases  this  year 
probably  exceeds  that  of  any  previous  year.  But 
it  must  be  remembered  that  in  1908  several  thou- 
sand cases  occurred  in  the  greater  city — possibly 
indeed  many  cases  of  and  deaths  due  to  the  dis- 
ease were  never  reported  as  such.  Hence  the 
present  experience,  Bevere  and  serious  as  it  is, 
is  not  something  new;  the  disease  has  been  Be 
verely  epidemic  before  and  was  brought  under 
control.  The  knowledge  regarding  it  now  is  far 
greater  than  it  was  iii  L908;  and  the  forces  of  the 
City    which    are    dealing    with    the    epidemic    are 

probably  better  organized  and  in  more  general 
co-operation  than  ever  before.  The  outlook, 
therefore,  should  not  be  regarded  as  discourag 

inir. 


20 


DATE  DUE 

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DEMCO  38-296 


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